In 1978, Oregon passed its first advance directive statute known as the “Directive to Physicians.” The directive was relatively narrow in scope, addressing a person’s wishes regarding cardiopulmonary resuscitation (CPR) should there be a complete cessation of heart and lung function. Recognizing the limited clinical utility, the Oregon legislature passed the current advance directive statute in 1993. The directive now includes a person's specific instructions about “life support” and “tube feedings” in each of four scenarios: close to death, permanently unconscious, advanced progressive illness and extraordinary suffering. The document was a major improvement in eliciting and recording a person’s values regarding life-sustaining treatments.

To honor the wishes of the very seriously ill, clinicians still needed a person’s values translated into actionable medical orders. The nascent Medical Treatment Coversheet and later POLST (including orders about CPR, ventilator use and tube feedings), became effective methods to help honor a seriously ill person’s wishes as expressed in the new advance directive. With these improved tools, health care professionals could translate their patient’s treatment preferences into medical orders, changing the way medicine was practiced. For example, use of tube feedings for those with advanced progressive illness became a more thoughtful consideration with a patient and loved ones. By the year 2000, in response to cautious discernment of growing data that feeding tubes did not extend life in this population, 2000, permanent feeding tube use dropped to near zero in Oregonian's with advanced dementia.